Answer :
Final answer:
In the event of a primigravida experiencing preterm labor with a suspected rupture of membranes, the nurse's immediate priority is to assess the fetal heart rate. This assessment determines if the fetus is in distress, which is critical for ensuring fetal safety. Other assessments, while important, should follow after confirming fetal wellbeing.
Explanation:
Understanding the Priority Action in Preterm Labor
In a scenario where a primigravida at 34 weeks gestation reports a sudden gush of water, indicating that her water has likely broken, the nurse's priority action is to assess the fetal heart rate. This is crucial because there is a risk of umbilical cord prolapse and other complications following the rupture of membranes, especially in preterm labor. The health and safety of the fetus must be the foremost concern.
Rationale for the Priority Action
Here are the key reasons:
- Fetal Heart Rate Assessment: Monitoring the fetal heart rate is essential to determine if the fetus is in distress due to the rupture of membranes.
- Imminent Delivery: While preparing for imminent delivery is critical if labor progresses quickly, confirming fetal well-being comes first.
- Cervical Dilation: Although assessing cervical dilation is important in labor management, it does not take precedence over fetal well-being immediately after water breaking.
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